Provider Demographics
NPI:1396827952
Name:SPARROW CLINTON HOSPITAL
Entity Type:Organization
Organization Name:SPARROW CLINTON HOSPITAL
Other - Org Name:UNIVERSITY OF MICHIGAN HEALTH-SPARROW CLINTON HOSPITAL EMERGENCY DEPAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SUPERVISOR, PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:MISTY
Authorized Official - Middle Name:GUNTER
Authorized Official - Last Name:RUSSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-253-6308
Mailing Address - Street 1:8175 RELIABLE PKWY
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60686-0081
Mailing Address - Country:US
Mailing Address - Phone:989-224-6881
Mailing Address - Fax:989-227-3347
Practice Address - Street 1:805 S OAKLAND ST
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-2253
Practice Address - Country:US
Practice Address - Phone:989-224-6881
Practice Address - Fax:989-227-3347
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPARROW HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-20
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0A960020OtherBCBSM BILL PIN
MI=========OtherMI LIENCE NUMBER